Between 1999 and 2005, 23 failed total ankle replacements were converted to arthrodeses. Three surgical techniques were used: tibiotalar arthrodesis with screw fixation, tibiotalocalcaneal arthrodesis with screw fixation, and tibiotalocalcaneal arthrodesis with an intramedullary nail. As experience was gained, the benefits and problems became apparent. Successful bony union was seen in 17 of the 23 ankles. The complication rate was higher in ankles where the loosening had caused extensive destruction of the body of the talus, usually in rheumatoid arthritis. In this situation we recommend tibiotalocalcaneal arthrodesis with an intramedullary nail. This technique can also be used when there is severe arthritic change in the subtalar joint. Arthrodesis of the tibiotalar joint alone using compression screws was generally possible in osteoarthritis because the destruction of the body of the talus was less extensive. Tibiotalocalcaneal arthrodesis fusion with compression screws has not been successful in our experience.

This paper describes the surgical indications and technique for lateral femoral cutaneous neurectomy in the hip following formation of a neuroma post surgery.

We would like to present a single surgeon series of the treatment of localised trochanteric pain post total hip replacement. It is believed that in certain cases localised pain in the line of the scar is attributable to formation of a neuroma of the posterior branch of the lateral femoral cutaneous nerve of the thigh.

Method We have reviewed a consecutive series of 5 patients who underwent this procedure for unremitting pain following THR. Of the 5 patients 4 underwent unilateral neurectomy and one underwent a bilateral neurectomy. All had persistent pain before the operation with a positive Tinnel’s test.

Results Of all the patients, 4 said that their pain was improved after the operation and would undergo the operation again. One had no improvement at all. None were worse after the operation.

Conclusion We believe selective neurectomy to be a good procedure in this often, difficult clinical situation.

Several case reports will highlight the findings on history and examination and the technique used.

Aim: To review results and complications of revision knee replacements.

Materials and Methods: We retrospectively reviewed 41 cases of cemented revision knee arthroplasty in 39 patients (15 male, 24 female) performed between 1993 and 2003. Data regarding clinical and functional outcomes and complications was recorded.

Results: Mean age at index (revision) operation was 67.8 years (32 to 86) and mean follow-up was 6.8 years (1.5 to 12). Average time to revision was 80 months (9 months to 23 years).

The indication for revision was aseptic loosening in 16 cases, and deep sepsis in 13 cases, (12 were done in 2 stages). Others included polyethylene wear in 4 knees, instability in 2, and 1 each of peri-prosthetic fracture, implant breakage and pain of undetermined origin. 3 revisions were performed for failed Link Lubinus patello-femoral replacement. Mean interval between staged procedures for sepsis was 2 months.

Reconstruction was performed using the Kinemax Revision system with the use of augments and stems. The modular rotating hinge was used in 4 cases. Surgical exposure included additional lateral release in 7 cases, tibial tubercle osteotomy in 4 and quadriceps snip in one.

Complications: Included 1 post-operative death due to haematemesis and 2 non-fatal cardiac complications. 1 patient was re-revised for aseptic loosening at 3.5 years, 1 needed an above knee amputation for intractable sepsis after multiple failed reconstructions and 1 is awaiting patellar revision.

At latest review, 7 patients had died due to unrelated causes with a pain free functioning knee prosthesis. Of the remaining 31, 26 patients had none or minimal pain. 21 were independently mobile with a satisfactory range of motion.10 patients needed a walking stick.

Conclusion: Revision total knee replacement can give satisfactory results in the short to medium term, although the complication rate can be significant. The procedure should be performed in specialist units. Revision in 2 stages for sepsis resulted in satisfactory control of infection in our study.

Introduction: The lower limb deformities in relation to hip dysplasia and genu valgum seen in Hurler’s Syndrome are well recognised. Bone marrow transplantation has improved the survival of patients with Hurler’s Syndrome, reversing many of the clinical features associated with it. This is of increasing importance because the musculoskeletal manifestations do not appear to be affected.

Methods: Between 1990 and 2003, 18 patients have been successfully engrafted and have been followed up for a mean of 6.8 years (range 18 months to 15 years) at Royal Manchester Children’s Hospital. We describe the lower limb problems and their management in these patients. We report on their skeletal development following successful transplant. Radiographic analysis was done using the following measurements where possible – acetabular index, centre-edge angle, migration percentage, femoral neck-shaft angle and tibio-femoral shaft angle.

Results: Of the 18 patients, one has had bilateral staged shelf acetabuloplasty and bilateral staged medial epiphyseal stapling (MES) of the upper tibia. The second patient has had bilateral upper tibial MES.

Discussion: There is very little in the literature on the long-term natural history of the orthopaedic manifestations of Hurler’s Syndrome after bone marrow transplantation. Presently there is no consensus as to the best management of the lower limb problems in this disorder. Well conducted long-term follow up is essential.

Aim: To determine the ultimate strength at failure of three different methods of repairing meniscal tears Method: Artiþcial tears were created in 21 fresh bovine menisci. These were then divided into three groups. Group one were repaired using a single 2–0 Ticron vertical suture. Group 2 were repaired using a single Clear-þx meniscal screw. Group 3 were repaired using a single Mitek fastener from the Mitek meniscal repair system. The repaired constructs were then loaded onto a tensiometer and distracted at a rate of 16mm/min. The extension during loading, maximum tensile strength and mode of failure were all recorded.

Results: The single vertical suture failed by breaking at the knot at a mean load of 64.38N and mean extension of 19.91mm. The Clearþx screw failed by pulling out of the peripheral portion of the meniscus. The mean load at failure of the Clearþx screw was 38.06N and mean extension was 17.10mm. The Mitek fastener failed by pulling out of the peripheral meniscus at a mean load of 15.50N and mean extension of 13.87mm.

Conclusion: The single vertical suture failed at higher loads than both the Mitek fastener and the Clearþx screw in the bovine meniscus.

Aims: To compare the results of early splintage against delayed splintage with ultrasound surveillance in neonatal hip instability. Methods: Between 1992 and 1997, all unstable hips (Ortolani or Barlow positive) referred by the Paediatric Department were seen within 1 to 2 weeks of birth. They were assessed clinically and by static and dynamic ultrasound. Those with proven instability were treated in a Wheaton Pavlick splint. Between 1998 and 1999, with the same assessments made, all hips with proven instability were treated by close surveillance in the form of serial ultrasound and were splinted if there was persistent instability or dysplasia. Any neonate presenting later than 2 weeks was excluded from this study. Results: From 1992 to 1997, 37 neonates were treated with 59 unstable hips. Mean time to splintage was 6.35 days (1–14 days), and mean splintage time was 6.13 weeks (4–11 weeks). All patients in this group developed normally, and no surgical intervention was required. From 1998 to 1999, 11 neonates were treated with 16 unstable hips. 9 hips required splintage after an average of nine weeks. 7 hips stabilised with no splintage. Two hips required surgical intervention, one for Ôlateñ dislocation and one for persistent dysplasia. These results show a statistically signiþcant difference for the two treatment groups. (p=0.04, Fishers exact test)Conclusion: We conclude from these results that neonatal hip instability is best treated by splintage within two weeks of birth.

Aim: The aim of this study was to determine the signiþcance of radiolucent lines observed around the MG unicompartmental knee replacement. Method: Weight bearing AP and lateral þlms of 75 knees were reviewed in 56 patients. Each patient had pre-op, post-op and up to date þlms reviewed. On each postoperative þlm the prosthesis was divided into zones. Each zone was observed for evidence of a radiolucent line suggestive of loosening. Results: 75 unicompartmental replacements were performed in 56 patients. The mean follow up was 67.2 months (24–112 months). The femoral component showed no radiolucent lines in any zone in 97% of the knees. 79% of the knees showed no radiolucent lines on the AP view of the tibial component and 71% showed no evidence of radiolucent lines on the lateral view of the tibial component. The most frequent observation was the presence of a radiolucency in zone 1 on both the AP and lateral view of the tibial component. The early appearance of a radiolucency in zone 1 did not progress to aseptic loosening of the implants. Conclusion: The femoral component of the MG implant very rarely shows evidence of radiolucent lines suggestive of loosening. The presence of a radiolucent line in zone 1 of the tibia on the AP or lateral þlm does not lead to early failure of the implant.

Aim: The aim of this research was to assess the difference in the observed tibiofemoral axis between long leg and short AP films of the knee.

Method: 20 patients who were undergoing primary total knee replacement, and had had no previous surgery on the affected limb were x-rayed using the a long leg cassette to include both the hip and ankle joints. A special screen was constructed to obscure all the x-ray except for a field, the size of a standard AP x-ray of the knee. The tibiofemoral angle was measured by two independent observers first on the short film and then on the long leg film.

Results: Our results have shown that the short leg film consistently overestimates the true tibiofemoral angle. Intraobserver correlation is also better when comparing the long leg film rather than the short film.

Conclusion: Measurement of the tibiofemoral or anatomical axis of the knee is best performed using long leg films, as this appears to give more consistent and reproducible results.

This study was undertaken between May 1992 and April 2002 in a hospital where there was a targeted screening programme for Developmental Dysplasia of the Hip. All data was collected prospectively. 2,578 infants with clinically unstable or at risk hips underwent bilateral hip ultrasound examination. This was performed by the senior author. At risk hips were considered to be those where there was a history of breech presentation, foot deformity, oligohydramnios on prenatal maternal ultrasound scans or a strong family history of Developmental Dysplasia of the Hip. There were significant changes in the reasons for referral for targeted screening over the ten year period. In the first year of the study 1.5% of referrals were because of oligohydramnios. In the last year of the survey 16.5% of referrals were because of oligohydramnios. The number of referrals for screening because of oligohydramnios increased sixty fold between the first year and last year of the study period. The overall number of infants referred for targeted screening more than doubled between the first and the last year of the study period. Of the infants that were found to have unstable or dislocated hips, no infants had oligohydramnios as a risk factor. The number of referrals for targeted ultrasound screening is increasing. In a targeted screening programme for Developmental Dysplasia of the Hip we suggest that oligohydramnios should not be used as a possible risk factor.

Aim: To compare the results of early splintage against delayed splintage with ultrasound surveillance in neonatal hip instability.

Methods: Between 1992 and 1997, all unstable hips (Ortolani or Barlow positive) referred by the Paediat-ric Department were seen within 1 to 2 weeks of birth. They were assessed clinically and by static and dynamic ultrasound. Those with proven instability were treated in a Wheaton Pavlick splint. Between 1998 and 1999, with the same assessments made, all hips with proven instability were treated by close surveillance in the form of serial ultrasound and were splinted if there was persistent instability or dysplasia. Any neonate presenting later than 2 weeks was excluded from this study.

Results: From 1992 to 1997, 37 neonates were treated with 59 unstable hips. Mean time to splintage was 6.35 days (1-14 days), and mean splintage time was 6.13 weeks (4-11 weeks). All patients in this group developed normally, and no surgical intervention was required. From 1998 to 1999, 11 neonates were treated with 16 unstable hips. 9 hips required splintage after an average of nine weeks. 7 hips stabilised with no splintage. Two hips required surgical intervention, one for ‘late’ dislocation and one for persistent dysplasia. These results show a statistically significant difference for the two treatment groups. (p=0.04, Fishers exact test)

Conclusion: We conclude from these results that neonatal hip instability is best treated by splintage within two weeks of birth.

To compare the current practice of ACL reconstruction in a District General Hospital against the recently produced BOA best practice guidelines, we have reviewed all ACL reconstructions performed at our institute from 1997 – 2001. We have assessed the interval from injury to reconstruction and the role of pre-operative assessment and education. We have assessed the standard of documentation regarding the in-patient stay and the surgery itself, including the grade of operating surgeon. Post-operatively, we have assessed the position of the grafts radiologically, and whether original levels of sporting activity were regained.

The average time from injury to first consultation in an orthopaedic clinic was 23.6 months. In respect of the admission notes, 77% had the history of injury and symptoms documented, and although all had a general pre-operative cardio-respiratory examination documented, none had evidence of examination of the relevant knee joint. Furthermore, none of the patients had the risks and benefits of the procedure documented at admission, and only one patient had been consented by the operating surgeon. Peri-operatively, all patients received both antibiotics and thromboprophylaxis, although only 21% had daily entries in the notes. The average post-operative follow-up was 9.1 months.

From this audit of our current practice, we have highlighted the following points :-

There is still an unacceptable delay in the diagnosis of ACL rupture.